helping make a contraceptive choice - health sciences...

Birth Control Options - Helping patients

make an informed choice Herbert L. Muncie, Jr. M.D.

Professor of Family Medicine

LSU School of Medicine – New Orleans

Ms. J

• 17 year old woman comes in to discuss

contraception

– Senior in HS; plans to attend State

University in the fall

– Physical exam normal; BP 110/64; BMI –

20.6 kg/m2

– LMP 2 weeks ago; non-smoker; no

headaches

– Currently using condoms regularly

Decision to delay pregnancy

• A woman’s decision to delay pregnancy

or prevent an unintended pregnancy is

very personal – the decision:

– Is influenced by her social norms &

cultural environment

– Her economic situation

– Her long-term goals

– Her personal uniqueness

Health Care Provider’s Role

• The health care provider’s role in the

woman’s decision process is to:

– Be knowledgeable about all options

– Provide unbiased nonjudgmental

information

– Listen to the woman’s concerns &

questions

– Give the best advice for that unique

patient

Contraceptive Success

• A woman’s ability to delay pregnancy &

prevent an unintended pregnancy

involves four components:

– Choosing and acquiring a contraceptive

method

– Accurately using the method

– Consistently using the method

– Switching methods correctly

Ms. J’s Birth Control Options

• Abstinence

• Condom

• Diaphragm/cervical

cap

• Natural family

planning

• Oral contraceptive

• Contraceptive Patch

• Hormonal vaginal

ring

• Injection q 3 months

• IUD

• Contraceptive rod

Abstinence

• Abstinence

– Delaying the onset of sexual activity until

older

– Safest way to avoid pregnancy and STD

– No randomized trials have shown efficacy

of physician counseling delaying onset

• Cultural norm establishes the prevalence of

delaying onset of sexual activity

– Still reasonable to discuss option to reduce

risk of undue peer pressure

Condoms

• Condoms

– Only method proven effective

for prevention of STDs

– Combine with more effective

method with new sexual partner

– Use may increase if discussed

as additional protection from

pregnancy (not prevent STD)

– Must be used at time of sexual

activity

Diaphragm & cervical cap

• Diaphragm & cervical cap

– Combined with contraceptive gel

– Can be put in several hours before

intercourse

– Must be left in 8 hours after intercourse

– Increased risk of UTIs (diaphragm)

Natural Family Planning

• Natural family planning

– No medication side effects

– Efficacy highly dependent on compliance

Ms. J’s Birth Control Options

• Abstinence

• Condom

• Diaphragm/cervical

cap

• Natural family

planning

• Oral contraceptives

• Contraceptive Patch

• Hormonal vaginal

ring

• Injection q 3 months

• IUD

• Contraceptive rod

What about an cOCP for Ms. J?

• Would a combination oral contraceptive

pill (cOCP) be appropriate for Ms. J?

– Does Ms. J have any contraindications to

using a cOCP?

cOCP Contraindications

• Smoking and ≥ age 35

• Uncontrolled hypertension

– Only clinical exam needed before starting

OCP is BP measurement (no pelvic exam)

– If >160/>100 do not use them

– If 140-159/90-99 or controlled “generally”

should not use them

• Migraine with aura (classic migraine)

cOCP Contraindications

• History of DVT, PE or arterial clotting

• A positive family history (FH) of clotting or

thrombotic events (relative contraindication)

–A positive FH is:

• If one parent or sibling ever had VTE < age 50 or

• If 2 relatives (either parents or siblings) had VTE at

any age

• Undiagnosed genital bleeding

cOCP Contraindications?

• Pregnancy – not harmful, just too late

• Sickle cell (SS) or sickle C (SC) disease

not absolutely contraindicated

– DMPA may be preferable for SS disease

– Associated with reduced risk of crisis

Which combination pill is best?

• cOCPs are a combination of an

estrogen & a progesterone -

– Primarily 3 estrogens & 9 progestins in

varying amounts & various combinations

Estrogen Dosages

• Ethinyl etradiol (EE) is most common estrogen used

• EE dosage is always ≤ 50 mcg – Most commonly prescribed pills have 30 - 35

mcg

– 20 mcg pill in randomized trial had reduced breast tenderness and bloating

– However, 20 mcg pills had a higher failure rate with missed pills

– 10 mcg pill approved (Lo-Loestrin®)

cOCP - Progesterones

Progesterone Class Family Examples

• Ethynodiol diacetate

• Norethindrone

• Norethindrone

acetate

1st

Generation

Estrane

(short

½ life)

Demulen® 1/35 Norinyl® 1/35,

Loestrin®

• Levonorgestrel (LNg)

• Norgestrel

2nd

Generation

Gonane

(longer

½ life)

Alesse®, Lybrel®,

Seasonale®,

Ovral®, Lo-Ovral®

• Desogestrel

• Norgestimate

• Dienogest

3rd

Generation

Gonane Desogen®, Mircette®,

Ortho Tri-Cyclen®

Natazia

Choosing the cOCP

• No pill has clinically significant advantage

– Low EE dosage may have fewer side effects

but may have higher failure rate

– Choice of estrogen or progesterone not critical

• Generally choose low to moderate dose

estrogen with 2nd generation progestin

– Then change pill if not tolerated

Benefits that could influence

choosing a cOCP

• Decreased dysmenorrhea

• Reduced menstrual flow

• Reduced risk of anemia

• Improves acne

• Eliminate mittelschmerz

• Decreased risk of

ectopic pregnancy

• Decreased risk of PID

• Decreased sxs of PMS

• Improvement in

endometriosis

• Suppression of ovarian

& breast cyst formation

cOCP – Cancer Benefit

• Endometrial cancer risk reduced

– 50% reduction if used in prior 12 months

– Maximum protection if use continues for

3 years

– Protection lasts for 15 + years

– High or low dose pills provide protection

cOCP – Cancer Benefit

• Ovarian cancer risk reduced

– 40% reduction in risk over nonusers

• High dose or low dose pills - same benefit

– Begins after 3-6 months of use

• 80% reduction after 10 years of use

– Reduced risk with family history ovarian

CA & 4-8 yrs. use

cOCP Risks

• What would be Ms. J’s risks in using a

cOCP?

cOCP & VTE Risk

• VTE Risk

– 3-6 fold increased risk VTE, highest first

6-12 months of use (SOR B)

– Older women have greater risk

• > age 39 - 100/100,000 women/year

• Adolescents - 25/100,000 women/year

• Pregnancy - 200/100,000 women/year

– Obesity doubles the risk

– Risk decreases with longer duration of use

VTE Risk & dropirenone/desogestrel

• Increased VTE Risk

– For same estrogen dose – drospirenone

(Yasmin®,Yaz®) & desogestrel (Desogen®, Mircette®)

have significantly higher VTE risk

• Absolute risk is low

• No study has found a reduced risk

• However, for women on these progestins would

need to change 10,000 to prevent 1 VTE

cOCP & Cardiovascular Risk

• Increased MI risk in smokers > age 35

– No increased MI risk with low dose pill for

non-smoking women, without hypertension

or migraine with aura at any age

• Increased risk of ischemic stroke

– 2-6 fold increase of ischemic stroke with

history of migraine with aura

• No increased vascular risk with progestin

only contraception

Cervical Cancer Risk

• Risks (SOR B)

– Increase in cervical cancer after 8 or more

years of use after adjusting for HPV infection

– Risk of CIN 2 or 3 with oncogenic HPV

• Decreased with depot-medroxyprogesterone (DMPA

- Depo-Provera®)

• No increase with cOCPs

cOCP & SLE

• cOCP use associated with increased risk

of developing systemic lupus

erythematosus (SLE)

– Especially if recently started

– However, very low absolute risk

• However, in women with previously

diagnosed SLE which is stable

– Starting a cOCP did not increase the risk of

flares

Not cOCP Risks

– No increased risk of weight gain (SOR A)

• Weight gain does occur with DMPA –

average of 5.1 kg

– No increased risk breast cancer (SOR B)

– No increased risk of death later in life

• In fact a net benefit was found

Frequency of menstruation?

• Before prescribing a cOCP ask how often

a woman wants to menstruate?

– Monthly? (every 4 weeks)

– Bimonthly? (Bicycling) (every 2 months)

– Quarterly? (Tricycling) (Every 91 days)

– Never?

Menstruate monthly or bimonthly

• Monthly (every 4 weeks)

–Use standard 28 pill cOCP

• Bimonthly (bicycling)

– Use 2 standard 28 pill cOCPs but skip the

placebo pills with the 1st pack

Menstruate Quarterly (Tricycling)

• Seasonale®

– 84 active pills [LNg (0.15 mg) & EE (30 mcg)] 7

placebo

– Increased risk of unsuspected bleeding first 6 months

of use

• Quartette® – increasing dosages of EE [LNg dosage

uniform (0.15 mg/day)]

– 42 days with 20 mcg EE

– 21 days with 30 mcg EE

– 21 days with 35 mcg EE

Menstruate never

• Lybrel® approved for continuous use

– 365 days active pills

– EE 20 mcg & levonorgestrel 0.09 mg every

day

cOCP - Other Formulations

OCP Active Placebo EE

Standard 21 7 0

Mircette® 21 2 5

Seasonique® 84 0 7

Lo-Seasonique® (20 mcg EE) 84 0 7

Loestrin® 24 Fe 24 4 0

Yaz® (20 mcg EE) 24 4 0

Femcon® Fe (chewable pill) 21 7 0

Natazia® 26 2 0

Beyaz ® (Yaz with folate); Safyral® (Yasmin

with folate)

24 4 0

What is the best way to

initiate a cOCP?

Starting cOCP – Sunday Start

“Sunday start” – take the 1st pill of the 1st

pack the 1st Sunday after onset of next

menses

– Reduces menses on weekend

– If start > 5 days from onset of menses

either abstain or use additional

contraception 1st 7 days of pills

Starting cOCP – 1st day Start

“First-day start” - take the 1st pill of the 1st

pack the 1st day of next menses

– Easier for patients to remember & to

explain to patient

– As long as start < 5 days from onset of

menses no additional contraceptive

needed

– Less breakthrough bleeding

Starting cOCP – Visit day start

“Visit day start” - take the 1st pill of the

1st pack the day of the visit

– “Quick start” - watch patient take 1st pill

• Negative pregnancy test & no intercourse prior

2 weeks, no immediate follow-up

• If intercourse within prior 2 weeks, repeat

pregnancy test in 2 weeks

• Additional contraception the first 7 days

Quick-Start Benefit

• Main benefit is reduced time explaining how to

start pills

– No evidence reduced risk of pregnancy or

discontinuation rates for OCPs

– Fewer women on quick-start Depo-Provera became

pregnant than women who started another method

• Other than the IUD, can start any contraceptive

immediately without UPT

– Can do UPT 2 – 4 weeks later if concerned about

pregnancy

Writing the OCP Prescription

• Ordering 13 packs at the

visit lead to better

continuation rates &

decreased cost

– Also were more likely to have

PAP & chlamydia screening

• Had fewer pregnancies

RX

Dr. Fleur de Lis

New Orleans, LA

Ms. R

Sig: 13 OCP Packs

Refill: x 0

Another OCP Prescription Option?

• Giving 7 packs lead to a

greater continuation rate

compared to giving 3

packs

• Women who received a

prescription were not more

likely to continue

compared to having the

packs in hand

RX

Dr. Fleur de Lis New Orleans, LA Ms. R

Giving 7 packs of pills at time of visit (not an Rx)

Missed Pills

Some women are excellent at taking the

pill consistently & some are not

No demographic characteristic can identify

which patient will remember consistently

Compliance was not enhanced with group

motivation, structured, peer or

multicomponent counseling or intensive

reminders

How many pills are missed?

Using electronic monitoring an average of

2.6 pills were missed each cycle.

However, in a text-messaging trial, the

average number of missed pills was

4.9 per cycle

No pregnancies occurred with this level of

non-compliance

Missed pill instructions

• First ask which pill was missed:

– If placebo pill just skip it

• If active pill and < 24 hrs late

– Take immediately

• If active pill and ≥ 24 but < 48 hrs late

– Take missed pill immediately & other pill at

usual time (may mean both at same time)

– Additional contraception not required

> 2 Missed pills

• If > 2 consecutive active pills missed

– Take most recent missed pill immediately (discard other missed pills)

– Take remaining pills at usual time (may mean two pills on the same day)

• If missed pills were in the last week of hormones (day 15 – 21), omit placebos and start new pack instead of placebos

– Use additional contraceptive method for 7 days

> 2 Missed pills (Cont.)

• If > 2 consecutive active pills missed

– Should consider emergency contraception if unprotected intercourse in previous 5 days or if missed pills during the 1st week

• May be considered at other times

– Discuss alternative contraceptive options that do not require daily compliance

Most Dangerous pill to miss?

• Most dangerous pill to miss

is the 1st pill of the new pack

– Pill free > 7 days increases

risk ovulation

• If miss 1st pill use additional

form of contraception until taken

7 consecutive active pills

• Stress compliance with starting

each new pack

Special Populations & cOCP

Postpartum

Breastfeeding

Seizure disorder on medication

Migraine headaches

Antibiotic concomitant use

Obesity

Postpartum

• ACOG guideline

– No cOCP < 21 days postpartum

(high risk of VTE)

– If not breastfeeding may start after 21 days if

no increased VTE risk (e.g. C-section)

– If C-section must wait 42 days (6 weeks) to

start cOCP

• For delivery of < 20 weeks gestation -

can begin cOCP immediately

Breastfeeding

• Progestin only pills are often recommended for women breastfeeding because:

– No effect on quality or quantity of breast milk

• They work by thickening cervical mucous & preventing sperm ascending through os

– However, erratic ovulation suppression

• Irregular bleeding common

Progestin only pills

• Daily compliance crucial

– Must take same time every day (> 3 hr difference can allow ovulation)

– If >3 hr delay occurs take pill immediately & use additional contraception until taken at correct time for 2 consecutive days

– Consider EC if unprotected intercourse

• Not contraindicated in smokers > age 35

• No increased risk of VTE

cOCP & Breast feeding

• Can start cOCP > 4 weeks post-partum

(PP) if lactation is well established &

other forms of contraception are not

acceptable

• If exclusively breastfeeding (> 85% of

feeds) no medical contraception needed*

*MMWR June 21, 2013

Seizure Disorder on Medication

• Some anticonvulsants reduce efficacy cOCP by increasing metabolism of EE & progesterone – Avoid cOCP with phenytoin, carbamazepine,

barbiturate, primidone, topiramate, oxcarbazepine

– Mirena®, Skyla® & Depo-Provera® not effected by these medications

– If cOCP is used with these medications, WHO advises either 50 µg EE pill or continuous cOCP

• These anticonvulsants do not effect cOCPs – – Gabapentin (Neurontin®), lamotrigine (Lamictal®),

levetiracetam (Keppra®), tiagabine (Gabitril®)

– However, cOCPs may lower lamotrigine levels

Migraine Headaches & cOCPs

• For migraine without aura cOCPs:

– May increase or decrease headaches

• Can give trial of cOCP and see what happens

– If HAs persist with normal BP & no deficit

• Lower dosage of estrogen, progestin or both (no

studies reported) SOR - C

– If HAs persist with increased BP or deficit

• Discontinue cOCP

• For migraine with aura cOCPs are

contraindicated

cOCPs & Concomitant Antibiotic

• CDC guideline – most antibiotics have no

effect on cOCP effectiveness

– No additional contraceptive method needed

– Except with griseofulvin & rifampicin

Contraception & Obesity

• What contraception is most effective for

obese women (BMI > 30 kg/m2)?

– Depo-Provera® & NuvaRing® are not affected

by body weight (SOR B)

– Obese women using cOCP or patch have

increased risk of pregnancy (SOR B)

HORMONAL CONTRACEPTION

TRANSDERMAL

TRANSVAGINAL

Contraceptive Patch (Transdermal)

• Ortho Evra® (EE 20 mcg; norelgestromin

150 mcg/day)

– Apply abdomen, buttocks upper torso

(exclude breast) or upper outer arm

– One patch a week for 3 weeks, 4th week

patch free

– Can use continuous patches for 12 weeks

Contraceptive Patch

(Transdermal)

• Equally efficacious to cOCP

– Less effective - women > 90 kg

• Side effects

– Breast discomfort, headache, nausea &

cramps – perhaps more than with cOCP

Hormonal vaginal ring (Transvaginal)

• NuvaRing® (EE 15 mcg & etonogestrel 12 mcg/day)

– One ring for three weeks

• No ring for one week

– Does not have to be in specific position

• Hormones absorbed anywhere in vagina

– If ring is out > 3 hours use additional

contraception until ring in place for 7 days

Hormonal vaginal ring

• NuvaRing®

– Contraceptive hormone levels last for 35 days

– Alternative regimen

• One ring every 30 days (once a month)

• Same day of the month (e.g. 12th of every month)

• Reduces number of menses & hormonal

withdrawal side effects

Patch or Ring vs cOCP?

• Cochrane review found:

– Patch caused more side effects than cOCP

– Ring caused fewer side effects than cOCP

• Except for vaginal discharge & vaginitis

• Compared to non-users same age, ring/patch

users had 6.5-7.9x increased risk VTE

– Increased SHBG & protein C sensitivity

– However, would need to switch 2000 ring or

1250 patch users to cOCP with levonorgestrel to

prevent 1 VTE

Ms. J’s Birth Control Options

• Abstinence

• Condom

• Diaphragm/cervical

cap

• Natural family

planning

• Oral contraceptive

• Contraceptive Patch

• Hormonal vaginal

ring

• Injection q 3 months

• IUD

• Contraceptive rod

Injection every 3 months

• Medroxyprogesterone acetate IM Q90D (Depo-Provera®; Depo-subQ Provera 104®)

– Associated with weight gain

– Irregular bleeding and most women are

amenorrheic at one year

– May have better compliance than cOCP

– FDA Black-Box Warning – Increased risk

of decreased BMD with > 2 years use

Ms. J’s Birth Control Options

• Abstinence

• Condom

• Diaphragm/cervical

cap

• Natural family

planning

• Oral contraceptive

• Contraceptive Patch

• Hormonal vaginal

ring

• Injection q 3 months

• IUD

• Contraceptive rod

Long-acting Reversible

Contraception (LARC) - IUD

• IUD – levonorgestrel

– 5 years duration (Mirena®)

– 3 years duration (Skyla®)

• Smaller & perhaps easier to insert

• IUD – intrauterine copper

– 10 years duration (ParaGard®)

– Can be used for emergency contraception up

to 5 days after unprotected intercourse

– Discrete method since will not effect

menstrual cycle regularity

LARC - Implant

• Etonogestrel SD (Implanon®; Nexplanon®-

radiopaque)

– Single subdermal rod for 3 years duration

LARC - Indications

• Indications

– Can be used in almost any female who

desires the most effective contraceptive

method

LARC – not contraindications

• Not contraindications to LARC are:

– Nulliparity

– Age – neither too young or too old

– Prior STD

– Prior ectopic pregnancy

– Prior PID

IUD Contraindications (risk>benefits)

• IUD contraindications – never to use

– Distorted uterine cavity

– Gestational trophoblastic disease

– SLE with positive antiphospholipid antibodies (exception ParaGard®)

– Pelvic tuberculosis

IUD Contraindications to Initiate

Use

• IUD contraindications to initiating use until

condition is treated

– Cervical cancer awaiting treatment or uterine

cancer

– AIDS, until clinically well on antiretrovirals

– Current PID or purulent cervicitis

– Postabortal or postpartum sepsis

– Unexplained or unevaluated vaginal bleeding

– Complicated solid organ transplant

– SLE with severe thrombocytopenia (exception

Mirena®)

Indications to Remove IUD

• Indications to remove IUD

– Headaches with aura that develop with use (exception ParaGard®)

– Ischemic heart disease that develops during

use (exception ParaGard®)

Implant contraindications

• Contraindications to ever using

– SLE with positive antiphospholipid

antibodies

• Contraindications (initiation of use) until

condition treated

– Unexplained or unevaluated vaginal

bleeding

Indications to remove implant

• Indications to remove implant

– Headaches with aura that develop with

use

– Ischemic heart disease that develops

during use

– Stroke during use

Advising a Contraceptive Method

• Before advising a woman regarding

contraception assess two things:

– First, how important is it to her that she not

become pregnant?

• The more important it is

• The more important to advise the most effective

method for her

– Second, what is her understanding of the

effectiveness of contraceptive options?

• She may have unrealistic understanding

Contraceptive Failure*

1000 women

No method

850

Withdrawal

Periodic abstinence

220

Condom

180

Diaphragm

120

cOCP

Patch

Ring

90

IUD

2

Implant

0.5

*Number of pregnancies during one year of typical use

The Contraceptive Recommendation

• Women overestimate the effectiveness of pills,

patch, ring or condom

• Risk of pregnancy is 20x greater for pill, patch,

or ring users compared to IUD, implants

– And women < 21 yo were 2x more likely than older

women to get pregnant with pill, patch or ring

• If delaying pregnancy is strongly desired

– Recommend IUD or implant (LARC)

• No clear best way to present this evidence to

women that allows for an informed choice

Providing Effective Counseling

• Characteristics of effective counseling:

– Demonstrate expertise, trustworthiness &

accessibility

– With adolescents address confidentiality

and parent’s role in the decision process

– Engage the woman in the learning process

– Address choosing the method, correct

use, consistent use and method switching

– Give priority to more effective methods

Providing Effective counseling (continued)

• Determine if method fits her lifestyle

(social norms, image, stigma, etc.)

• Recommend condom use with any

method as “extra” protection from

pregnancy (does reduce risk of STD)

• Discuss how to avoid inconsistent use

• Address side effects at the beginning

Key Points

• Multiple contraceptive options exist with

moderate to excellent efficacy

– Moderate – cOCP, patch, ring, depo

– Excellent – IUD, implant

• Know the main benefits and risks for

each method

– If prescribe a cOCP use “visit day” start

Key Points

• Generally recommend a LARC method

for women whom delaying pregnancy &

preventing unintended pregnancy is

highly valued

– Essentially very few contraindications to

LARC methods

• Provide “effective” counseling

Ms. J’s Conclusion

• Ms. J strongly does not want to become

pregnant in the near future

• After reviewing her options she

chooses to have an implant placed

Questions